As I walked into the NICU I could see the fear in the eyes of the young couple. There tiny little baby had been born weeks before the due date and was not feeding. The neonatologist had warned them earlier in the day that the surgeon would be coming in later to take a look at him. The baby in question here was a tiny little thing with a huge tummy that was red and shiny. I knew even before seeing the X rays that the child was having a hole in the intestines and would probably require a major surgery. The X rays confirmed my fears, the child had free air in the abdomen and would require an urgent surgery! With my mind made up, I proceeded to talk with the parents. Over the next hour I explained in detail about the problem that the baby was having my plan to try and take him back to health. I took them through the steps of the surgery and the likely outcomes. When the possible need for a stoma was discussed, they were very apprehensive and intimidated about it especially the prospect of caring for the baby with a stoma at home.
The bowel stoma is a common outcome of new born abdominal surgeries. Though from the surgeon’s point of view it is a simple and effective solution to tide over the immediate dangers for the baby, the parents are often intimidated and find themselves under a lot of stress while caring for their child. I shall attempt here to answer some of the frequent questions that I have come across during my practice as a paediatric and neonatal surgeon.
What is a Stoma?
The surgeon operates and opens the intestines of the baby on the tummy of the child to create a stoma. The baby passes stools and gas from this opening instead of normal anal opening.
When the small intestines are opened on the skin it is called an “ileostomy “. The same in the large intestine is called a “colostomy”.
Why is a stoma constructed?
When the surgery is either too risky or the baby is very small the surgeons create a stoma as a temporary measure. In certain conditions like imperforate anus, Hirschsprung’s disease etc, the baby is too small to do a definitive surgery. Here a stoma acts as a temporary outlet for the stools. When the baby becomes older and bigger the surgeon can correct the underlying disease and close the stoma.
In other conditions like Necrotising enterocolitis, bowel perforations, peritonitis the baby might be very sick or there might be a lot of disease in the intestines. In such a situation the baby might not survive a prolonged or extensive surgery. The construction of a stoma is a fast and effective measure to allow for passage of stools and feed the child early in the post-operative period. When the baby is better and is gaining weight the stoma may be closed.
How is a stoma closed?
Before the stoma can be closed the surgeon will ascertain if the child has recovered from the primary disease completely and that the bowels are completely healthy. Additional Xray studies will need to be done. Once all the preparations are made the surgeon disconnects the intestines from the skin stitches the two ends of the bowel together (anastomosis). This is done under general anaesthesia and child may need 5-7 days to recover from the surgery.
Does my baby need special care because of the stoma?
A new born is essential delicate and a lot of care and attention is required for them. Having said that the presence of a stoma does not require any exceptional care. The parents can give bath and massages to the baby as normal. Once the stoma is properly dressed the baby can be made to wear the normal clothes. There is no special attention that needed while holding, feeding and carrying the baby.
How to do a stoma dressing?
There are many methods of stoma dressing the most common and convenient method is using a stoma bag. The stoma bags are made of plastic and have a wafer that adheres to the skin. The stools collect in the bag and may be drained periodically. These bags come in various sizes for babies of different age and weight. The stoma care nurse come and fit the child with the appropriately sized bag and teach the parents how to replace the bags. Once the parents are adept and confident at managing the stoma bag then the baby is discharged to home care.
Some babies do not however do well with bags. This may be due to the fact that the perfect size is not available or the fact that the child is very active and the bags leak frequently. Further some parents might not be able to afford stoma bags for an extended period. These children are managed with cloth dressing. In this a barrier cream is applied on the skin around the stoma after which a soft cloth, soaked with oil is placed on it. This is then secured with an abdominal tie.
What are the common problems that may be with stomas?
The most common problem expected after the stoma construction is skin irritation around the ostomy. This is because of prolonged contact of the stools with the skin. At times this can be severe enough to cause superficial skin wounds. This is manged by application of barrier creams. Sometimes it might require more than one method to control the rash. Skin irritation can be avoided by ensuring tight seal between the stoma bag and the 0stomy so that there is no leakage. In case the baby is having a cloth dressing then care must be taken to frequently change the same
Some times the stoma might bleed. The tissue is very delicate and touching it or minor trauma can lead to bleeding from the stoma. This is usually self-limiting and does not require any treatment. If the child is having frequent bleeding, then care need to be taken to make sure that the cloth is not very rough or the edges of the bag are not sharp.
The other uncommon problems may be a shrinking of the stoma, bulging at the time of stoma and or the prolapse of intestines from the stoma. In case any of these happen then the parents need to visit the paediatric surgeon for advice of proper care.
What will be the long-term effect of the stoma on the life of my child?
Stomas created for babies are temporary and are usually closed by the time the child is 6 months to 1 year old. Once the stoma is closed the child usually recovers well and there are no long-term sequelae because of the stoma. The child might have a scar at the operated site that usually fades with time. Most of the children are expected to have a normal and fruitful life.
Regarding the baby that I was talking about at the start. She underwent the surgery and came out with a stoma that was subsequently closed when she was 6 months old. Today she is a happy and healthy 2-year-old. The parents keep sending me her smiling pictures time and again.